HospitalInspections.org

Based on document review and staff interviews the facility staff failed to ensure an updated History and Physical was performed on a patient, Patient #9 who was readmitted following a stay in an acute facility.

The findings include:

Patient #9 was first admitted to the facility on 8/20/1978 with the diagnoses of Spina Bifida, Seizure Disorder and Chronic Respiratory Failure. Patient #9 was discharged to an acute care facility on 2/20/11 where He/She remained overnight. Patient #9 was then readmitted to this facility on 2/21/11. Patient #9 last History and Physical was documented in the current medical record on 6/24/08.

Employee #2 stated, "There should have been a new History and Physical performed per our bylaws. If a patient is discharged and readmitted a new History and Physical should be performed."

Based on interviews and document reviews the facility staff failed to maintain an accurate medical record for 4 of 9 patient medical records (Patient #2, 3, 5 and 6) reviewed.

The findings include:

Patients #2,3,5 and 6 medical records were reviewed on 7/31 and 8/1/13.
Patient #2 was originally admitted the facility on 12/22/11. Patient #2's readmission History and Physical dated 1/4/13 dictated and signed as complete and accurate by the attending physician on 1/5/13 stated Patient #2 was married. Patient #2 has never been married and has a court appointed guardian.

Employee #1 stated, "He has never been married."

Patient #3 was originally admitted to the facility on 5/20/13 with the diagnoses of End Stage Renal Disease, Below the Knee Amputation, Failure to Thrive, pneumonia and diabetes. The attending physician dictated a progress note dated 6/18/13 and signed the note as being accurate on 6/24/13. The noted stated, "Tracheostomy site looks clean....PEG site looks clean." Patient #3 did not have a tracheostomy or a PEG. This information was errored out and initialed on 7/12/13 by a member of the medical records staff.

Employee #1 stated, "(He/She) should not have errored out that information the physician should have done that when they signed the note. And He/She should not have errored out the information after the physician signed it."

Patient #5 was admitted the facility on 4/4/13 transferred to an acute facility on 6/28/13 and readmitted on 7/30/13 to this facility. Patient #5 dictated discharge note dated 7/1/13 indicates Patient #5 was evaluated by Neurology. The evaluation by Neurology could not be located.

Employee #1 stated, "I can not locate a note written or dictated that indicates He/She was seen by neurology."

Patient #6 was admitted on 7/16/13 with the diagnoses of MRSA, Diabetes, status post amputation and debridement of the 3rd, 4th and 5th metatarsals on the right foot. Patient #6 was discharged on 7/30/13. The attending physician dictated a discharge summary on 7/31/13. The note stated, "...who had right below the knee amputation at (Name of hospital). He/She later developed a bout of foot cellulitis. He/She apparently developed severe infection which required amputation of the 3rd, 4th and 5th metatarsals and debridement of the necrotic tissue..."

Employee #1 stated, "The patient did not have a below the knee amputation. I will see that this is corrected."